Chapter 16

Otitis Media Case Study

Answers

1. Correct Answer: D) Erythematous and bulging tympanic membranes bilaterally.  While options A, B, and C are part of Mateo’s presentation, they do not necessarily require immediate follow-up.  Option D, Erythematous and bulging tympanic membranes bilaterally, is a hallmark sign of acute otitis media and requires immediate follow-up to assess for other symptoms, such as pain, fever, and irritability, and to administer prescribed medications.
2. Correct Answer: A) Acute pain related to inflammation of the middle ear. Acute pain is the most immediate and significant concern for Mateo.  Addressing his pain will also likely improve his appetite and overall comfort, making his other symptoms easier to manage.  Risk for fluid deficit may be an appropriate diagnosis, but Mateo’s acute pain takes priority.  Mateo may be at risk for impaired hearing due to his chronic ear infections, but there is nothing to indicate that Mateo is having hearing difficulty at this time.  Answer choice D may be appropriate, but it is not the priority nursing diagnosis.
3. Correct Answer: C) Reassess Mateo’s pain level and vital signs and notify the provider of his response to the medication.  It is important to reassess Mateo after the initial intervention and communicate his lack of improvement to the provider. This allows for further assessment and potential adjustments to the treatment plan.  This is not a normal reaction to pain.  It would be unsafe to give a second dose of acetaminophen so soon after the first dose.  Distraction may help Mateo cope with his pain, but it is not the best answer choice available.
4. Correct Answer: B) Verify Mateo’s identity using the client armband and confirm with the parents. Prior to administering any medication, it is crucial to correctly identify the client using two identifiers, a standard safety practice in healthcare.  Option C is not appropriate as the nurse giving the medication should perform the verification.  Option A disregards the critical safety step of client identification, and option D delays essential documentation, potentially leading to errors.
5. Correct Answer: A) The importance of finishing all antibiotics as prescribed, even if symptoms improve.  This is crucial to prevent antibiotic resistance and ensure complete resolution of the infection. Options B, C, and D are incorrect and could be potentially harmful to Mateo.
6. Correct Answer: B) If his fever comes back in a few days, we can give him ibuprofen instead of acetaminophen.  While ibuprofen is also an effective antipyretic, it is important to clarify with the provider before administering a new medication to Mateo.  Additionally, return of his fever could indicate that the initial infection is not resolving.  The other options demonstrate understanding of discharge instructions: A) emphasizes the importance of completing the antibiotic course, C) identifies appropriate monitoring and follow-up, and D) acknowledges the need for adequate hydration.

Pediculosis Capitis Case Study 

Answers

1. Correct Answer: A) Assess Sofia’s scalp for the presence of live lice and nits. This aligns with the assessment phase of the nursing process, as it focuses on gathering objective data to confirm the suspected diagnosis of pediculosis capitis. While options B, C, and D are relevant to the overall plan of care, they are not the immediate priority in the initial assessment.
2. Correct Answer: B) Wash all bedding and clothing used by Sofia in hot water and dry on high heat. This directly addresses the highly contagious nature of lice and their eggs. While options C and D are relevant for general infection control, they are less impactful than environmental decontamination. Option A provides symptomatic relief but does not address the root cause of the infestation.
3. Correct Answer: A) Impaired Skin Integrity related to scratching and irritation of the scalp. This diagnosis accurately reflects Sofia’s primary issue, the irritated scalp. While options C and D may be relevant, they are not the primary nursing diagnosis in this scenario. Option B is incorrect because the case study states there are no open lesions.
4. Correct Answer: B) It is essential to repeat the treatment with the cream in 7 days, even if no lice are seen. This ensures proper treatment and prevents reinfestation.  A second application is necessary to kill any newly hatched lice from nits that survived the first treatment.  The cream should also be applied to dry hair, not wet.  Furthermore, it needs to remain on the hair for ten minutes, not thirty.  The permethrin cream will not continue to kill lice for two weeks, so a second application is necessary.  The hair should be combed for nit removal for longer than three days after treatment.
5. Correct Answer: A) Provide Sofia and her mother with detailed written and visual instructions on combing out nits. This aligns with the planning and implementation stages of the nursing process by addressing an essential aspect of lice treatment and prevention. Option B is not within the scope of the nurse’s responsibilities.  Options C and D are not indicated in this case study.
6. Correct Answer: A) Assess Sofia’s scalp for the presence of live lice and nits at a follow-up appointment in one week. This aligns with the evaluation phase of the nursing process and directly measures the treatment’s effectiveness. While options B and C provide helpful information, they are not the most direct measures of treatment success. Option D is not feasible or ethical.

Please find answers to the Learning Activity interactive elements within the element.